Coping

Objectives – The student will be able to …

• Explain the concept of coping (including definition, antecedents,
and attributes).
• Analyze conditions which place a patient at risk for
Ineffective/Maladaptive Coping.
• Identify when Ineffective/Maladaptive Coping is developing or
has developed.
• List key points of common Ineffective/Maladaptive Coping
disorders.
• Apply the nursing process (including collaborative interventions)
for individuals experiencing Ineffective/Maladaptive Coping and
to promote Effective/Adaptive Coping.
Definition of Coping
• Multiple definitions
• All definitions include an emotional and/or physical
response to a change in one’s status or environment in
order to reduce stress

• Easier to define ineffective/maladaptive coping

 Definitions of Coping
• An ever changing process involving both cognitive means and
behavioral actions, in order to manage internal or external
situations that are perceived as difficult and/or beyond the
individual’s current resources (Giddens, 2013)

• The changing thoughts and behaviors that people use to

manage distress (emotion-focused coping) and the problem
underlying the distress (problem-focused coping) in the context
of a specific stressful encounter or situation (Folkman, n.d.)

• Adapting to and managing change, stress, or opportunity, such

as those associated with acute or chronic illness, disability, pain,
death, relocations, work, changes in family structure, new
relationships, or new ideas-that is, the expected (Tabers, 2013)
Selye’s
General Adaptation Syndrome
Any event (stressor) that threatens an individual leads to a
3 stage response
• Alarm
• Resistance
• Exhaustion

• “Fight or flight” response

http://www.youtube.com/watch?v=N5txl89dzv8
Alarm Stage
• Brain activity
• Hypothalamus stimulates the sympathetic nervous system
• Pupils dilate
• Bronchioles dilate, respiratory rate increases
• Cardiac contractility, HR, BP, and cardiac output increase
• Sweat gland secretions increase
• Adrenal medulla
• releases norepinephrine
• releases epinephrine (adrenolin)
• Adrenal cortex produces corticosteroids
• Glycogenolysis and gluconeogenesis increase
• Glycogen synthesis decreases
• Endorphins are released
Resistance Stage
• Adaptation stage
• Outward appearance seems normal
• HR remains elevated
• Glucose and hormone levels remain high
• Muscle perfusion is increased
• GI perfusion, motility and secretions decrease
• Remain “On alert”

• Failure to resolve stressor leads to next stage

Exhaustion Stage
• Stressors continue beyond the individual’s resources
• Resources are depleted
• Susceptible to physical and emotional disease and death
During which stage of the GAS will the
heart rate increase, breathing
quicken and pupils dilate?

A. Alarm
B. Resistance
C. Exhaustion
D. Recovery
Reflective Exercise
Describe a stressor
that you’ve experienced?

How did you respond?

Rate your coping ability

on a scale of 1-10.

What would have helped

you cope better?
Ego Defense Mechanisms
• Denial • Sublimation
• Undoing • Compensation
• Acting out • Assertiveness
• Dissociation • Suppression
• Regression • Identification
• Projection • Introjection
• Displacement • Isolation
• Intellectualization • Humor
• Reaction formation
You tube video of defense
mechanisms http://tinyurl.com/6em34lk
Have each pair of Have students take turns
students discreetly select presenting the skits.
a defense mechanism
from the previous list.

Allow 5 minutes to
research and develop a
30-60 second skit
demonstrating the use of Encourage the class to
this defense mechanism. guess which defense
mechanism is in play.
Which defense mechanism is being
used when a student yells, “I would
have done better if you didn’t make
the test so hard.”

A. Regression
B. Intellectualization
C. Displacement
D. Reactive formation
Key Points of Coping
• Coping can apply to an individual, a family, or an entire
community
• Coping occurs along a spectrum from effective/adaptive
responses to ineffective/maladaptive responses
• Coping may be problem focused or emotion focused
• All individuals use coping mechanisms regardless of race,
sex, or gender.
• Outcomes of coping range from resolution to acceptance
Antecedents of Coping -
• Individual perceptions
• Insight and honesty
• Individual boundaries
• Life experiences
• Anticipation
• Positive defense mechanisms
• Ability to cognitively and emotionally appraise and
manage internal and/or external situations
• Available resources and support systems
• Relationships with people
• Relationships with environment
Attributes of Coping -
• Calm affect
• Positive coping mechanisms
• Effective and age appropriate communication
• Ability to perform ADLs and IADLs
• Use of available support systems
How do you know a patient is
effectively coping?
A. The patient is anxious
but working on the
assigned task.
B. The patient is
watching TV and
ignoring the therapist
C. The patient clearly
states his needs
D. The patient gets up to
the bathroom without
necessary assistance.
Desired Coping Response
• Results in resolution of stressor(s) if possible
• Results in acceptance of stressor(s)
• Requires full cognitive capacity
• Culturally sensitive and diverse

Individual evaluation
• Primary appraisal - Is the stressor a threat?
• Secondary appraisal - Can the individual overcome the
stressor?
Risk Factors
• Impaired cognition
• Inability to accurately assess the stressor
• Denial or avoidance of the stressor (negative defense
mechanisms)
• An actual or perceived lack of control over the situation
• An actual or perceived lack of support/resources
• No experience or poor past experiences handling
stressful situations
• Age
• Deterioration in Health or Chronic Health Conditions
Consequences of Poor Coping
• Maladaptive coping responses can lead to physical
and/or psychosocial problems
• Highly variable
• Type and number of stressors
• Perception of stressors
• Length of time that stressor occurs
• Type of coping mechanism implemented
• Resilience of individual
• Previous experiences
• State of health
• Available resources
Consequences of Poor Coping
• Decline in physical health
• Peptic ulcer disease
• Hypertension
• Decline in mental health
• Isolation
• Depression
• Alteration in functional ability
• Job loss
• Poor hygiene
• Alteration in family dynamics
• Separation/divorce
• Poor communication
Which one of the following is not a
consequence of maladaptive coping?
A. Sue scores 74 on her biology
exam after studying all night
and forgoing sleep.
B. John’s heartburn rarely occurs
now even though his workload
stayed the same.
C. Wes is living on the street after
he argued with his parents
D. Mary is still with her boyfriend
even though she no longer
loves him.
Sub Concepts
• Anxiety
• Stress
• Substance Abuse/Addictive Behaviors
• Adaptability
• Conflict resolution

• All will be discussed later and in more detail as students

progress through the nursing program
Interrelated Concepts
• Immunity
• Comfort
• Functional ability
• Mobility
• Nutrition
• Sensory perception
• Sleep
• Sexuality
• Tissue integrity
• Cognition
• Mood and affect
• Communication
• Health Promotion
Assessment
• History
• Perception of Threat
• Past Coping Patterns
• Social
Family dynamics/friends
Work/recreation
Living environment
Financial
Assessment
• History continued
• Medical
General state of health
Illnesses
Surgeries
Medications
Treatments
Use of alcohol, tobacco and/or drugs
Neuro-vegetative changes
Assessment
• General examination (observable)
• General description and appearance
• Behavior
• Communication/Speech
• Content of thought
• Mood, affect and feelings
• Judgment/Insight
• Physical examination
Assessment
• Screening tools
• Global mental health assessment tool
• Self-HARM assessment tool
• CAGE-Alcohol misuse screening tool
• Assessment scales
• Mini Mental State Examination
• Sleep Scale
• Beck Anxiety Inventory Scoring for Children
• Mainz coping inventory
• Coping strategy inventory
Nursing Diagnoses
• Ineffective/Maladaptive Coping
• Compromised Family Coping
• Ineffective Community Coping
• Readiness for Enhanced Coping
Outcomes/Patient Goals
• Patient will display Effective/Adaptive Coping
• Patient will display Readiness for Enhanced Coping
• Patient will use Effective/Adaptive Family Coping
• Patient will use Effective/Adaptive Community Coping

• Patient will attend counseling bi-weekly

• Patient will follow medication regime
• Patient will state improvement in mood
• Patient’s blood pressure will be normalized
Nursing Interventions
• Accept patients where they are
• Assist with ADLs and IADLs
• Provide an environment of acceptance
• Quiet and safe environment
• Utilize therapeutic communication
• Encourage verbalization of feelings, perceptions, and
fears
• Assist patient to recognize his or her own anxiety
• Reinforce that shame and guilt are self imposed
• Identify stressors related to the present physical
condition
Nursing Interventions
• Identify ways to modify or eliminate the stressors
• Improve psychological and physiologic comfort
• Anxiolytics
• Assist in the development of effective coping skills
• Interactive therapies
• Behavioral modifications
• Acknowledge the patient’s spiritual/cultural background
• Discourage decision making when the patient is under
severe stress
Nursing Interventions
• Primary prevention
• Teach stress reduction
• Teach coping skills
• Identify available resources and supports
• Secondary prevention
• Various assessment and screening tools
• Tertiary prevention
• Continued counseling
• Providing referrals to available resources and supports
Nursing Interventions
• Critical skills
• Assessment of coping response
• Therapeutic communication
• De-escalation techniques
• Medications
• Collaborative interventions
• Psychiatry
• Psychology/counseling
• Social work
• Play or art therapy
• Occupational/physical therapy
• AA or other 12 step program
What is the priority intervention
for a patient in distress?
A. Escort patient to the
therapist’s office.
B. Medicate as
prescribed
C. Assist patient with
eating
D. Encourage
communication